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2. 
3. FPD | CRB Complaint Form
   REGARDING ACTIONS OF FERGUSON POLICE DEPARTMENT EMPLOYEES
5. If you have any questions, please call FPD at (314) 522-3100 and ask for the supervisor on duty or leave a message in the CRB voicemail box at (314) 521-7721 ext. 7053.
7. Your Information (optional)
   The Ferguson Police Department and the Civilian Review Board respect your privacy and will not distribute your personal information (if you choose to provide it) except as necessary to resolve your complaint or as required by state law. You may omit personal information on this form if you wish to make an anonymous complaint. We encourage you to provide as much information as possible so that investigators can speak to relevant witnesses and gather evidence.
9. First Name
10. Middle Initial
11. Last Name
12. Preferred Pronoun
14. Your Street Address
16. City
17. State
18. Zip
20. Phone Number (for contacting you)
21. Email Address (for contacting you)
23. Race
24. Gender Identity
25. Age
27. Citizen-Police Mediation Program*

    FPD has a Citizen-Police mediation program to resolve certain types of complaints. Participation is completely voluntary. Would you consider mediation for this complaint?

    1. Yes
    2. No
    3. Maybe
31. Incident Information (required)
33. Location*
34. Incident Date and Time*
    Incident Date and Time

    Incident Date and Time
36. Officer/Employee Name (or description if unkown)*
38. How many people witnessed the incident?*
    Note: If more than 5 please provide names and contact information in the incident description.
40. Witness Name (First & Last)
41. Witness #1 Contact
43. Witness Name (First & Last)
44. Witness #2 Contact
46. Witness Name (First & Last)
47. Witness #3 Contact
49. Witness Name (First & Last)
50. Witness #4 Contact
52. Witness Name (First & Last)
53. Witness #5 Contact
55. Related Police Report or Incident Number (if known)
57. Setting of Incident (check all that apply)*

    1. Home
    2. School
    3. Business

    1. Street
    2. Other
58. Other Setting
60. Do you have video and/or photographs relevant to this incident?*

    1. Video
    2. Photo(s)
    3. None
61. Upload Video(s)
62. Upload Photo(s)
64. Statement/Description of Incident*
66. Do you have additional document(s)/statement(s) you would like to include?

    1. Yes
    2. No
67. Upload Documents
Leave This Blank:


69. 1. Receive an email copy of this form.
70. Email address

    This field is not part of the form submission.

71. Submit

* indicates a required field